Diagnosis of ear pain

Abstract

Many patients in primary care present with ear pain (otalgia). When the ear is the source of the pain (primary otalgia), the ear examination is usually abnormal. When the ear is not the source of the pain (secondary otalgia), the ear examination is typically normal. The cause of primary otalgia is usually apparent on examination; the most common causes are otitis media and otitis externa. The cause of secondary otalgia is often difficult to determine because the innervation of the ear is complex and there are many potential sources of referred pain. The most common causes are temporomandibular joint syndrome, pharyngitis, dental disease, and cervical spine arthritis. If the diagnosis is not clear from the history and physical examination, options include a trial of symptomatic treatment without a clear diagnosis; imaging studies; and consultation with an otolaryngologist. Patients who smoke, drink alcohol, are older than 50 years, or have diabetes are at higher risk of a cause of ear pain that needs further evaluation. Patients whose history or physical examination increases suspicion for a serious occult cause of ear pain or whose symptoms persist after symptomatic treatment should be considered for further evaluation, such as magnetic resonance imaging, fiberoptic nasolaryngoscopy, or an erythrocyte sedimentation rate measurement.

Full text

Diagnosis of Ear Pain
JOHN W. ELY, MD, MSPH; MARLAN R. HANSEN, MD; and ELIZABETH C. CLARK, MD, MPH
University of Iowa Carver College of Medicine, Iowa City, Iowa
E
ar pain (otalgia) is a common symp-
tom in primary care with many pos-
sible causes. When the cause arises
from the ear (primary otalgia), the
ear examination is usually abnormal and the
diagnosis is typically apparent. In secondary
or referred otalgia, the ear examination is
usually normal, and the pain may be referred
from a variety of sites.
The ear receives sensation fibers from cra-
nial nerves V (trigeminal), VII (facial), IX
(glossopharyngeal), and X (vagus), and cer-
vical nerves C2 and C3. These nerves have
long courses in the head, neck, and chest,
which is why so many diseases can cause
ear pain. The structures of the inner ear
(i.e., cochlea and semicircular canals) are
innervated by cranial nerve VIII (vestibulo-
cochlear), which has no pain fibers. There-
fore, most pathologic processes of the inner
ear do not produce pain.
1
However, inner ear
diseases such as Meniere’s disease can pro-
duce other sensations, such as pressure or
fullness (online Table A).
1
It is often stated that 50 percent of
pain in the ear is secondary otalgia,
1
and that
50 percent of secondary otalgia results from
dental causes
2
; however, these estimates are
not based on published data. In a study of
500 patients visiting an ear, nose, and throat
clinic, 58 presented with primary otalgia
and 28 with secondary otalgia.
3
In another
study involving 615 patients, the most com-
mon causes of secondary otalgia were dental
(38 percent), temporomandibular joint
(TMJ) disorders (35 percent), cervical spine
disorders (8 percent), and neuralgias (5 per-
cent).
4
The causes of otalgia in children are
similar to those in adults, although middle
ear disease (especially acute otitis media) is
more common in children.
5
Clinical Evaluation
HISTORY
Key points in the history include the patient’s
age, the location of pain (asking the patient to
point with one finger), the radiation of pain,
aggravating factors (e.g., chewing), associ-
ated symptoms (otologic and systemic), and
risk factors for tumor (e.g., age older than
Many patients in primary care present with ear pain (otalgia). When the ear is the source of the pain (primary otal-
gia), the ear examination is usually abnormal. When the ear is not the source of the pain (secondary otalgia), the ear
examination is typically normal. The cause of primary otalgia is usually apparent on examination; the most com-
mon causes are otitis media and otitis externa. The cause of secondary otalgia is often difficult to determine because
the innervation of the ear is complex and there are many potential
sources of referred pain. The most common causes are temporoman-
dibular joint syndrome, pharyngitis, dental disease, and cervical
spine arthritis. If the diagnosis is not clear from the history and phys-
ical examination, options include a trial of symptomatic treatment
without a clear diagnosis; imaging studies; and consultation with an
otolaryngologist. Patients who smoke, drink alcohol, are older than
50 years, or have diabetes are at higher risk of a cause of ear pain that
needs further evaluation. Patients whose history or physical exami-
nation increases suspicion for a serious occult cause of ear pain or
whose symptoms persist after symptomatic treatment should be con-
sidered for further evaluation, such as magnetic resonance imaging,
fiberoptic nasolaryngoscopy, or an erythrocyte sedimentation rate
measurement. (Am Fam Physician. 2008;77(5):621-628. Copyright ©
2008 American Academy of Family Physicians.)
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ILLUSTRATION BY JOAN BECK
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Ear Pain
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Evidence
rating References
Magnetic resonance imaging and referral for nasolaryngoscopy should be considered for patients with
otalgia who have a normal ear examination and who have signs, symptoms, or risk factors for tumor
(e.g., tobacco or alcohol use, age older than 50 years).
C 1, 5
Young (i.e., younger than 40 years), otherwise healthy adults with otalgia and a normal ear examination
can be treated symptomatically. Referral is appropriate if symptoms persist.
C 1, 2
Patients older than 50 years with unexplained otalgia and a normal ear examination should have
an erythrocyte sedimentation rate measurement to help rule out temporal arteritis.
C 25
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 579 or http://
www.aafp.org/afpsort.xml.
622 American Family Physician www.aafp.org/afp Volume 77, Number 5
◆
March 1, 2008
Management of Ear Pain
Patient presents with ear pain
Perform ear examination
Abnormal ear
examination,
cause apparent
Subtle ear findings Normal or equivocal ear examination
Treat
Rule out “worst-case scenario”
1. Cholesteatoma (superior tympanic
membrane retraction pocket)
2. Malignant (necrotizing) otitis externa
(diabetes, immunocompromise)
Basic evaluation
1. Examine nose, oropharynx, neck, and chest
2. Examine TMJ
3. Audiometry, finger rub, or whispered voice
4. Tympanometry or pneumatic otoscopy
5. Tap on teeth
Refer to otolaryngologist
If cause not apparent, rule
out worst-case scenario
Risk factors for coronary disease
or thoracic aneurysm
Older than 50 years Low risk for worst-case scenario
(e.g., healthy young adult)
Risk factors for malignancy (e.g., alcohol
or tobacco use, age older than 50 years)
Consider imaging or
nasolaryngoscopy
ECG, chest radiography,
troponin measurement
ESR to help rule out
temporal arteritis
Evaluation normal
Observe or treat empirically (e.g., NSAIDs, soft diet)
Follow up
Evaluate further or refer if persistent symptoms
Figure 1. Algorithm for the management of ear pain. (TMJ = temporomandibular joint; ECG = electrocardiography;
ESR = erythrocyte sedimentation rate; NSAIDs = nonsteroidal anti-inflammatory drugs.)
Information from references 1, 4, and 6.

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March 1, 2008
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Volume 77, Number 5 www.aafp.org/afp American Family Physician 623
50 years, tobacco or alcohol use). Otologic symptoms
that favor a primary cause include discharge, tinnitus,
hearing loss, and vertigo. The severity of pain is not nec-
essarily correlated with the seriousness of the cause. For
example, the pain from tumors can be mild, whereas the
pain from dental caries and otitis media can be severe.
PHYSICAL EXAMINATION
Key components of the physical examination include
inspection of the auricle and periauricular region and
a thorough otoscopic examination, which may require
cerumen removal. Tenderness that occurs with traction
on the auricle (online Figure A) or pressure on the
tragus (online Figure B) indicates a condition of the
external auditory canal, usually otitis externa.
When the ear examination is normal, the physician
should palpate the TMJ for tenderness and crepitus as the
patient opens and closes the mouth (online Figure C).
In addition, the basic examination should include
inspection of the nose and oropharynx, palpation of the
head and neck, and examination of the cranial nerves. The
gingiva should be inspected and palpated and the teeth
inspected and percussed to assess tenderness. Fiberoptic
nasolaryngoscopy is not usually necessary. Patients may
need this procedure if they have risk factors for tumor or
if conservative measures do not resolve symptoms.
DIAGNOSTIC TESTS
An assessment of hearing, by audiometry or simple test-
ing (i.e., finger rub or whispered voice), is indicated in
patients who notice hearing loss. An assessment of tym-
panic membrane mobility with pneumatic otoscopy
or tympanometry can be helpful if there is suspicion
of middle ear disease. When the physical examination
is normal and the goal is to rule out tumor, the patient
should have nasolaryngoscopy and magnetic resonance
imaging (MRI) of the head and neck with gadolinium
contrast.
4
When the disease is evident on examination
and the goal is to determine the extent of involvement,
computed tomography (CT) with contrast media is gen-
erally indicated. For example, temporal bone trauma
should be evaluated with CT scanning.
CLINICAL APPROACH TO DIAGNOSIS
Referring to a list of the causes of otalgia (Tables 1
through 4,
1,4,6-39
online Table A) may be helpful, but
in many patients these causes do not seem to fit. When
the evaluation is unrevealing, a diagnosis of possible
TMJ syndrome or eustachian tube dysfunction is often
made. The physician must then decide whether to treat
the patient symptomatically or to evaluate further with
MRI or fiberoptic nasolaryngoscopy. Figure 1 provides
one approach to this decision.
1,4,6
In a patient at low
risk of tumor or other serious illness, it is reasonable to
offer symptomatic treatment (e.g., nonsteroidal anti-
inflammatory drugs and a soft diet if TMJ syndrome is
suspected). If conservative measures are not helpful, MRI
or a more invasive examination should be considered.
RULE OUT WORST-CASE SCENARIO
As with any symptom, a “rule out worst-case scenario”
strategy (in which certain diagnoses must be ruled out
immediately) may help avoid serious diagnostic errors.
40
In patients with otalgia, physicians should rule out sev-
eral potential causes that can have serious consequences
if the diagnosis is delayed; these are malignant (necro-
tizing) otitis externa, cholesteatoma, myocardial infarc-
tion, temporal arteritis, and malignant tumor. However,
these diseases can often be ruled out on the basis of a
nonworrisome history and physical examination rather
Table 1. Common Causes of Ear Pain: Abnormal Ear Examination
Cause History Physical findings Comments
Otitis media
7
Recent upper respiratory infection
Night restlessness in children
Red or cloudy tympanic membrane that
is immobile on pneumatic otoscopy
Most common cause of primary ear pain
More common in winter
Otitis
externa
8
Recent swimming
White discharge
Pain elicited by traction on auricle or
pressure on tragus
External auditory canal swollen and
red with white debris
1
Findings can be subtle (consider empiric
therapy)
More common in summer
Consider malignant (necrotizing) otitis
externa in patients with diabetes or
immunocompromise
Foreign body
9
Insects, small objects
Commonly occurs in children
Foreign body visible in ear canal May need sedation for removal
Barotrauma
10
Pain onset during descent of
airplane or while scuba diving
Tympanic membrane hemorrhage
Serous or hemorrhagic middle ear fluid
Otoscopic signs of barotrauma are
present in 10 percent of adults and
22 percent of children after an airplane
flight
10
Information from references 1 and 7 through 10.

Ear Pain
624 American Family Physician www.aafp.org/afp Volume 77, Number 5
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March 1, 2008
than extensive testing. Risk factors that should prompt
consideration of these diseases are outlined in Table 5.
Common Causes of Ear Pain
ABNORMAL EAR EXAMINATION
Acute otitis media is probably the most common cause
of primary otalgia (online Figure D).
1,7,41
The tym-
panic membrane is classically red and bulging, but it
can also be white or pink, and the discoloration some-
times involves only part of the tympanic membrane.
Otitis externa (or swimmer’s ear) generally leads to
swelling and redness of the ear canal. There is often
debris in the ear canal or covering the tympanic mem-
brane.
8
Subtle otitis externa can be difficult to identify
on inspection, but it usually causes tenderness when the
examiner pulls on the auricle or presses on the tragus
(online Figures A and B).
Foreign bodies in the ear canal are most com-
mon in children. In one study, the most common
objects removed were beads, paper, popcorn kernels,
and insects.
9
Most foreign bodies can be removed under
direct visualization with a curette or alligator forceps.
If this is not successful, the child should have removal
of the foreign body under sedation and otomicroscopy.
9
Although most foreign bodies in the ear canal can be
managed nonurgently, hearing-aid batteries should be
removed promptly to prevent alkali burns.
Barotrauma typically occurs while scuba diving or
during an airplane flight with the onset of pain during
descent.
10
Eustachian tube dysfunction caused by an
upper respiratory infection or allergic rhinitis increases
the risk of barotrauma. The tympanic membrane is
typically hemorrhagic, and there may be blood or serous
fluid in the middle ear.
NORMAL EAR EXAMINATION
TMJ syndrome is characterized by pain and crepitus with
talking or chewing, and tenderness or crepitus on palpa-
tion of the TMJ joint (online Figure C).
11
It causes ear
pain, especially with chewing.
11
However, TMJ crepi-
tus is prevalent, and its presence should not prematurely
halt further investigation into other causes of otalgia.
1
Dental causes of otalgia generally involve the molar
teeth. A variety of dental diseases can produce otalgia,
but the most common are caries, periodontal abscesses,
and impacted third molars. The physician should pal-
pate the gingiva and tap on the teeth with a tongue blade
to assess for tenderness.
2
Pharyngitis and tonsillitis often cause referred pain to
the ear. In some patients with pharyngitis, ear pain can
be the primary complaint even when the ear is normal.
Idiopathic otalgia is common, but patients and phy-
sicians can be uncomfortable with this diagnosis.
4,6,13
If
a thorough evaluation is unrevealing and the physician
suspects a benign cause, empiric treatment for TMJ syn-
drome with nonsteroidal anti-inflammatory drugs and
a soft diet would be reasonable (Figure 1
1,4,6
). If the phy-
sician suspects neuropathic pain, a trial of gabapentin
(Neurontin) or amitriptyline is reasonable.
Uncommon Causes of Ear Pain
ABNORMAL EAR EXAMINATION
Malignant otitis externa is defined by osteitis of the skull
base, typically caused by Pseudomonas infection, and it
Table 2. Common Causes of Ear Pain: Normal Ear Examination
Cause History Physical findings Comments
TMJ syndrome
11
Pain or crepitus with
talking or chewing
Tender TMJ
Crepitus or clicking on motion of mandible
May have restricted jaw movement
Risk factors include clenching and
biting inside of lips and mouth
Dental causes
(e.g., caries,
periodontal abscess,
impacted third
molars, pulpitis)
6
May have dental
complaints or
history of dental
disorders
Caries
Abscess
Gingivitis
Facial swelling
Teeth tender to percussion
Caries and abscess most common
Pharyngitis or
tonsillitis
4
Often accompanied
by sore throat
Pharyngeal or tonsillar erythema
Swelling
Exudate
Otalgia can be the primary symptom
even if ear not involved
Cervical spine
arthritis
4,12
Crepitus or pain with
neck movement
Decreased neck range of motion
Tender spinous processes or paraspinal muscles
Pain referred from C2, C3 cervical
nerve roots
Idiopathic
4,6,13
Variable Normal In practice, often labeled TMJ
syndrome, neuropathic pain, or
eustachian tube dysfunction
TMJ = temporomandibular joint.
Information from references 4, 6, and 11 through 13.

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usually occurs in patients with diabetes or immunocom-
promise.
1
It is characterized by severe, deep, unrelenting
pain and by granulation tissue, which can be a subtle
finding, on the inferior aspect of the external auditory
canal at the bony-cartilaginous junction. Squamous cell
carcinoma of the external auditory canal can mimic
malignant otitis externa.
Ramsay Hunt syndrome (herpes zoster oticus) typi-
cally causes ear pain, facial paralysis, and vesicles in the
external auditory canal. Other symptoms can include
hearing loss, tinnitus, vertigo, taste disturbance, and
decreased tearing.
15
The syndrome is caused by herpes
zoster involving the geniculate ganglion (cranial nerve
VII), and it often involves cranial nerves V, IX, and X in
addition to the facial nerve.
Relapsing polychondritis is a systemic disease that
involves cartilage. It can affect many organs, including
the eyes, nose, heart, kidneys, and nervous system, but
the most commonly affected organ is the ear.
17
Relapsing
polychondritis often affects both ears, producing a red
or violaceous auricle. Sparing of the earlobe, which lacks
cartilage, helps distinguish auricular chondritis from
cellulitis. It is diagnosed by its relapsing course and typi-
cal appearance.
Cholesteatomas are epidermal cysts composed of des-
quamating epithelium. They gradually enlarge and can
erode the ossicular chain, inner ear, and bony facial nerve
canal. Cholesteatomas generally do not cause severe
pain, but may produce a sense of fullness. In patients
with otorrhea or conductive hearing loss, it is important
Table 3. Uncommon Causes of Ear Pain: Abnormal Ear Examination
Cause History Physical findings Comments
Malignant
(necrotizing) otitis
externa
14
*
Suspect in refractory otitis externa in
patients with diabetes, older patients,
and those with immunocompromise
Pain disproportionate to examination
findings
Granulation tissue on floor
of external auditory canal
Easy to miss, findings can be subtle
Obtain technetium bone scan to
determine extent of disease and
gallium tagged white-cell scan
as baseline to follow response to
treatment
Ramsay Hunt
syndrome (herpes
zoster oticus)
15,16
Pain often precedes vesicles and is much
worse than in Bell’s palsy
Patient may have vertigo, hearing loss,
or tinnitus
Vesicular rash on auricle and
external auditory canal
Palsy of cranial nerve VII
(facial)
Can involve other cranial
nerves (e.g., V [trigeminal], IX
[glossopharyngeal], X [vagus])
Pain can occur without significant
vesicular eruption
Cellulitis/chondritis/
perichondritis
Preceding insect bite, scratch, or piercing
Rapid progression
Perichondritis characterized by persistent
redness, swelling, and pain
Earlobe usually involved
with cellulitis
Perichondritis must be treated
aggressively; sometimes requires
parenteral antibiotics
Relapsing
polychondritis
17,18
Recurrent swelling and redness of auricle
Hearing loss frequent
Earlobe is spared because
it has no cartilage
Noninfectious
Can involve other cartilage such as
trachea and bronchi
Trauma
19
Blunt or sharp trauma
Frostbite
Burns
Traumatic lesions of auricle,
ear canal, or tympanic
membrane
Most common injury is laceration
of the auricle
Mastoiditis
20
Recent or concurrent otitis media
Retroauricular pain
Protrusion of auricle
Tender edematous mastoid
Prevalence increased in children
with limited access to health care
Tumors or infected
cysts in auricle or
ear canal
Pain usually well localized to auricle
or ear canal
May require meticulous
examination of external
auditory canal
May need to remove cerumen
Diagnosis of ear canal tumors
is often delayed because
of misdiagnosis as chronic
inflammation
Wegener’s
granulomatosis
Arthralgia
Hearing loss
Myalgias
Oral or nasal ulcers
Otorrhea
Rhinorrhea
Often causes chronic otitis
media or serous otitis
Consider testing for antineutrophil
cytoplasmic antibodies
Viral myringitis
21,22
Presentation similar to acute otitis media Tympanic membrane red, but
not bulging; landmarks visible
Bullous myringitis is not
pathognomonic of viral myringitis
*—Rule out “worst-case scenario” diagnosis (see Table 5).
Information from references 14 through 22.

Ear Pain
Table 4. Uncommon Causes of Ear Pain: Normal Ear Examination
Cause History Physical findings Comments
Tumors (e.g., parotid,
hypopharynx, nasopharynx,
base of tongue, tonsillar
fossa, larynx, esophagus,
intracranial, cervical spine)
4
Risk factors include smoking,
alcohol use, age older
than 50 years, hoarseness,
dysphagia, radiation
exposure, weight loss
May require fiberoptic
nasolaryngoscopy
Consider referral for invasive
examination and MRI
Neuralgias (e.g., trigeminal,
glossopharyngeal,
geniculate, sphenopalatine)
1,4
Pain usually brief (seconds),
severe, lancing, jabbing,
electric-shock–like, episodic
Usually none
May have trigger point
Trigeminal neuralgia (tic douloureux)
best defined
Bell’s palsy
23,24
Retroauricular pain, less severe
than Ramsay Hunt syndrome;
can precede or follow the palsy
Peripheral facial palsy
(involvement of
forehead)
Pain occurs in 25 to 50 percent of
patients with Bell’s palsy
Temporal arteritis
25
* Age older than 50 years
Jaw claudication
Diplopia
Temporal arteries may
be tender, prominent,
or beaded
Erythrocyte sedimentation rate usually
greater than 50 mm per hour
Biopsy and prompt treatment are indicated
Oral aphthous ulcers Localized pain in mouth as well
as ear
Shallow ulcers with
gray, necrotic base
Often recurrent
Etiology not well defined
Cervical adenopathy May have recent upper
respiratory infection or scalp
lesion
Tender cervical or
periauricular lymph
nodes
Consider CT and fine needle aspiration
for lymph nodes > 1.5 cm, lasting
longer than six weeks
Myofascial pain, muscle
spasm or inflammation of
sternocleidomastoid or
muscles of mastication
26,27
Pain aggravated by chewing or
head movement
May have trigger point Can be caused by clenching, bruxism,
TMJ syndrome, and dental or oral
disorders
Eagle’s syndrome (elongation
of styloid process)
28
Deep, unremitting pain
exacerbated by swallowing,
yawning, or chewing
May have pain in neck, foreign
body sensation in throat
Reproduce pain
with tonsillar fossa
palpation
Diagnosed with CT
Most patients are 3 to 40 years of age
and have had a tonsillectomy
Styloid process longer than 1 inch
(2.5 cm)
Sinusitis/sinogenic referred
pain from allergy
29
Nasal congestion
Pain in maxillary sinuses
Nasal congestion
Tender over maxillary
sinuses
Sinusitis is common but otalgia from
sinusitis is unusual
Carotidynia
30
May have dysphagia and throat
tenderness
Tender carotid artery More common in women
May have abnormal enhancement on MRI
Thyroiditis May report pain in thyroid Thyroid may be tender
or enlarged
Referred pain from cranial nerve X
(vagus)
Salivary gland disorders
(e.g., stones, mumps)
Pain in preauricular area Prominent, tender
parotid glands
There have been recent epidemics of
mumps in the United States
Cricoarytenoid arthritis
31
Ear pain and hoarseness
Pain is worse with speaking,
coughing, or swallowing
May have other
features of
inflammatory arthritis
Often caused by rheumatoid arthritis or
systemic lupus erythematosus
Gastroesophageal reflux
32,33
Heartburn
Acid reflux
Usually none Pain caused by irritation of oropharynx
(cranial nerves IX [glossopharyngeal]
and X) or of eustachian tube orifice
Angina pectoris, myocardial
infarction
34
*
Cardiac risk factors Usually none If suspected, obtain electrocardiogram
and serum troponin level
Thoracic aneurysms
(e.g., innominate artery,
thoracic aorta)*
More common in older men
May have hypertension and other
risk factors for atherosclerosis
May have chest or
back pain
Obtain chest CT scan or magnetic
resonance angiogram; plain chest
radiography is insensitive
Psychogenic (e.g., depression,
anxiety)
35
History of depression or anxiety Blunted affect
Depressed mood
Consider in patients with idiopathic
otalgia
Other rare causes (e.g.,
subdural hematoma, lung
cancer,
36,37
* central line
placement,
38
pillow otalgia,
39
carotid artery aneurysm)
Variable Variable Lung cancer is the best described of
these rare causes
MRI = magnetic resonance imaging; CT = computed tomography; TMJ = temporomandibular joint.
*—Rule out “worst-case scenario” diagnosis (see Table 5).
Information from references 1, 4, and 23 through 39.

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to visualize the most superior aspect of the tympanic
membrane to exclude a superior retraction pocket lead-
ing to a cholesteatoma (Figure 2).
NORMAL EAR EXAMINATION
Tumors in the nose, nasopharynx, oral cavity, orophar-
ynx, hypopharynx, infratemporal fossa, neck, or chest
can cause ear pain. The most common sites are the base
of the tongue, tonsillar fossa, and hypopharynx.
4
Risk
factors for head and neck tumors include tobacco or
alcohol use, dysphagia, weight loss, radiation exposure,
hoarseness, and age older than 50 years.
24
Neuralgias can involve cranial nerves V and IX, the
geniculate ganglion (cranial nerve VII), and the spheno-
palatine ganglion (cranial nerves V and VII). The best
known of these is trigeminal neuralgia (tic douloureux),
which is characterized by paroxysmal, sharp, lancinating
pain in the distribution of the maxillary and mandibular
divisions. Glossopharyngeal neuralgia causes pain in the
tonsillar area, pharynx, and, in some patients, the middle
ear; this pain may be elicited by palpation of the tonsillar
region.
2
Sphenopalatine neuralgia results in pain around
the eye and nose in addition to the ear and mastoid.
2
Bell’s palsy is characterized by the sudden onset of
upper and lower facial paralysis. Postauricular pain
occurs in about 25 percent of patients.
23
Patients may
also have hyperacusis, taste disturbances, and decreased
tearing.
Temporal arteritis often causes temporal pain and
tenderness that can involve the ear. Other symptoms
include malaise, weight loss, fever, and anorexia. It
is important to recognize temporal arteritis because
it can cause permanent blindness, but this is usually
preventable with prompt initiation of systemic corti-
costeroids. Only about 40 percent of patients have ten-
derness in the temporal arteries, but 65 percent have at
least one temporal artery abnormality (e.g., tenderness,
absent pulse, beading, prominence).
25
Although tem-
poral arteritis is unusual in patients younger than
50 years, it should be considered if there are multiple
findings indicative of the disease.
25
The disease is rare in
patients with normal erythrocyte sedimentation rates
and unusual if the erythrocyte sedimentation rate is less
than 50 mm per hour.
25
The Authors
JOHN W. ELY, MD, MSPH, is a professor of family medicine at the University
of Iowa, Iowa City. He received his medical degree from the State Univer-
sity of New York Upstate Medical Center in Syracuse. Dr. Ely completed a
family medicine residency at the University of Washington, Seattle, and a
fellowship in faculty development at the University of Missouri, Columbia.
MARLAN R. HANSEN, MD, is an assistant professor of otolaryngology—
head and neck surgery at the University of Iowa. He received his medical
degree from the University of Chicago (Ill.) Pritzker School of Medicine.
Table 5. Risk Factors for “Worst-Case Scenario”
Diagnoses in Patients with Ear Pain
Risk factor Possible diagnosis
Age older than 50 years, ESR greater
than 50 mm per hour
Temporal arteritis
Coronary artery disease risk factors Myocardial infarction
Diabetes or immunocompromise Malignant (necrotizing)
otitis externa
Tobacco and alcohol use, dysphagia,
weight loss, age older than 50 years
Head or neck tumor
Superior tympanic membrane
retraction pocket, otorrhea
Cholesteatoma
Unilateral hearing loss Malignant otitis externa,
cholesteatoma
ESR = erythrocyte sedimentation rate.
Figure 2. Two examples of cholesteatoma.
A
B

Ear Pain
628 American Family Physician www.aafp.org/afp Volume 77, Number 5
◆
March 1, 2008
Dr. Hansen completed an otolaryngology residency at the University of
Iowa and a fellowship in otology at the House Ear Clinic, Los Angeles,
Calif.
ELIZABETH C. CLARK, MD, MPH, is currently assistant professor of fam-
ily medicine at the University of Medicine and Dentistry of New Jersey,
Robert Wood Johnson School of Medicine, New Brunswick. At the time of
writing the manuscript, she was an assistant professor of family medicine
at the University of Iowa. Dr. Clark received her medical degree from the
University of North Carolina School of Medicine, Chapel Hill, and com-
pleted a family medicine residency and public health fellowship at the
Oregon Health and Science University, Portland.
Address correspondence to John W. Ely, MD, MSPH, Department of
Family Medicine, 01291-D PFP, University of Iowa Carver College of
Medicine, 200 Hawkins Dr., Iowa City, IA 52242 (e-mail: john-ely@
uiowa.edu). Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
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